At 1:55 p.m. EDT, just before I went out the door, my secretary asked, “Did you feel that?”
At 1:57 I heard Rush Limbaugh’s stand-in say they’d felt an earthquake in New York, with reports soon following of a quake centered near Washington, D.C. Apparently sensitive individuals as far northwest as Akron, Ohio felt it as well.
The Pentagon, the Capitol, the city of D.C. – all evacuated.
Usually these “minor” events take on a bit of a holiday atmosphere. The danger appears minimal, and a little time off work is always welcome. And fortunately, most earthquakes do not cause widespread injury.
However, today’s quake can serve as a wake-up call for those of us less familiar with the aftermath of serious earthquakes.
The CDC offers a starting point for earthquake preparedness at: http://www.bt.cdc.gov/disasters/earthquakes/. The site offers good advice for citizens on what I would call a “controlled disaster,” one in which neither mass panic nor significant injury occurs. Today is a good day to print it out, read it, follow it, and store it. (Will your computer be working when things go bad?)
Readers of Armageddon Medicine may want to investigate further regarding severe injuries that often occur with a serious earthquake. The CDC’s bioterrorist site on Crush Injuries and Crush Syndrome (see http://www.bt.cdc.gov/masscasualties/blastinjury-crush.asp) estimates the incidence of crush syndrome as 2-15% of quake-related injuries, with half the affected individuals developing acute renal failure, and half of them requiring dialysis. Clearly, this is ICU-level care involving an entire medical team. Professionals may want to think through how to handle such a situation without back-up care. The death rate of patients suffering crush syndrome could easily approach 50%.
After the Haiti quake, of those treated at a hospital, the CDC reports:
The most common injury-related diagnoses were fractures/dislocations, wound infections, and head, face, and brain injuries. The most common surgical procedures were wound debridement/skin grafting, treatment for orthopedic trauma, and surgical amputation. Among patients with earthquake-related injuries, the most common mechanisms recorded were cut/pierce/struck by an object and crush.
(See http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5951a1.htm)
Blast injuries are further enumerated and described at: http://www.bt.cdc.gov/masscasualties/blastinjuryfacts.asp.
Some of our professionals have visited Haiti after the 2010 earthquake. Would any of you care to comment (anonymously, or otherwise) on what you saw or experienced while there?
Or how about this question: what is the most complex medical situation that you have successfully handled without benefit of X-rays, labs, nursing, supplies, or back-up – a real end-of-the-world-as-we-know-it-scenario?
A classic austere case I took care of involved an untreated abscess on the shin bone. The patient presented on the street in a very unsecure area. I had about 20 minutes. Using betadine, clean gloves, and a #15 blade I opened the abscess only to discover the tibia was involved with oseomyelitis. I debrided an area of soft infected bone, by tactile and visual inspection, the size of a small grape. I irrigated with bottled water by drilling a hole in a cap and squeezing the bottle for a jet of water, or just pouring it in the wound with a scrubbing motion using the back side of the scalpel handle. I closed the muscle over the bone and left the rest of the wound open for healing by secondary intent. I gave Tequin as the available broad spectrum antibiotic in my bag. I saw him in passing about 6 weeks later, wound closed, looked good, walking on it just fine. There was no further follow-up.
Ideally pre-op x-ray would identify the osteo. Better follow-up and a second debridement 24-48 hour later would be considered, IV antibiotics are good, although some of the quinolones have great rapid onset and great bone penetration. In the developing world, quinolone resistance is sometimes not an issue in antibiotic-naive areas. Two-drug therapy would be a good thing to consider. A sterile field would be good. I did have plenty of sunlight, but an assist with a head lamp or a signal mirror could augment this.
A candle or lantern and a head mirror reflecting the light in a dim room can be quite satisfactory low-tech solution as a plan C when power goes out during a case. Plan B is bright headlamps. Plan A is a real OR spotlight.
For limb surgery in really dirt-blowing or insect-filled environments, first ask yourself, do I really need to do this here and now? (think compartment syndrome) If so, I usually place the prepped extremity in a sterile clear plastic bag (used to cover x-ray in surgery, any plastic bag is clean enough, though.) Seal the top with coban or tape and cut a small hole where you intend to do the procedure. Drop in the bag all your instruments and gauze. Run an IV tube in for irrigation. Cut a hole in the bottom of the bag to direct the drainage or put suction in the bottom of the bag. Place your hands in the bag with sterile gloves and do the procedure through the hole. Dress the wound and consider keeping the bag on the wound, based on environmental issues like water or dirt in the environment. I have done a lot of simple procedures this way in the past. Sometimes you just cant get a clean OR.
A simple urine dipstick looking for myoglobin can assist in screening those crush or burn patients with a potential kidney problem in a limited resource setting. You only need to do more extensive lab work on those who test positive.
pa4ortho
Thank you, pa4ortho, for this example example. Those of us practicing in suburbia seldom happen across the opportunity to think on our feet. There was that time, though, when a patient stopped by, having spilled his McDonald’s coffee in his lap while driving, sustaining second-degree burns to his privates. We headed for the side yard and irrigated with a garden hose, for better and quicker effect than was available inside.
Obama was asked about the earthquake and replied it wasn’t his fault and that he inherited it from George Bush. But it would have been worse without his administration’s efforts.